to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action. An important heuristic of IHI is the Triple Aim. IHI advocates for organizations and communities to aim to improve population health and the experience of care while reducing per capita cost. As of 2020, founder Donald Berwick continues to serve on the Board of Directors, Kedar Mate serves as President and CEO and Michael Dowling serves as Board Chair. Institute for Safe Medication Practices The Institute for Safe Medication Practices (ISMP), based in suburban Philadelphia, is a nonprofit organization devoted to preventing medication errors and the safe use of medications. Its medication error prevention efforts began in 1975 with a column in Hospital Pharmacy to inform healthcare professionals and others about medication error prevention. ISMP operates a voluntary practitioner error-reporting program to tabulate errors nationally, understand their causes, and share “lessons learned” with the healthcare community, known as the Medication Errors Reporting Program (MERP), operated by the United States Pharmacopeia (USP) in cooperation with ISMP. In addition, ISMP's corporate subsidiary, Med-E.R.R.S. (Medical Error Recognition and Revision Strategies), works directly and confidentially with the pharmaceutical industry to prevent errors that stem from confusing or misleading naming, labeling, packaging, and device design. The ISMP list of error-prone abbreviations is distributed nationally. The Joint Commission Founded in 1951, the Joint Commission (TJC, previously abbreviated as JCAHO) is an independent, not-for-profit organization that evaluates and accredits nearly 15,000 health care organizations and programs in the United States. An organization must undergo an on-site survey by a Joint Commission survey team at least every three years. The scope of reviews by TJC is broad, including hospitals, home care agencies, medical equipment providers, nursing homes, rehabilitation facilities, surgical centers and medical laboratories. Passing a survey is crucial for most organizations, since accreditation by TJC is required for participation in Medicare and some state and private health care programs. Since the accreditation rate is over 90%, there have been questions raised regarding the effectiveness of these surveys. In 1997, TJC began including outcomes and other performance data into the accreditation process (the "ORYX initiative"). Information gained allowed the Joint Commission to develop National Patient Safety Goals to promote specific improvements in patient safety. The Goals highlight problem areas in health care and describe evidence-based solutions. Examples include prevention of falls, patient